Provider Demographics
NPI:1962935312
Name:MITCH BACON LLC
Entity type:Organization
Organization Name:MITCH BACON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:603-667-3282
Mailing Address - Street 1:7454 N MONTEITH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4004 SE WOODSTOCK BLVD
Practice Address - Street 2:#9
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7662
Practice Address - Country:US
Practice Address - Phone:503-766-5255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1282106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty